Start your secure virtual checkup with Refua. This intake collects only what’s needed to coordinate your appointment and request your prior records under Ontario privacy law. All information is encrypted and stored in Canada.
Before you begin
• Government-issued photo ID (for verification)
• Previous doctor/clinic details (name; address/phone if known)
Step 1 — Patient information
Full Name · Date of Birth (YYYY-MM-DD) · Email Address · Phone Number · Province of Residence:
Ontario · Preferred Language: English
Step 2 — Previous provider
Previous Doctor / Clinic Name · Clinic Address (if known) · Phone/Fax (if known)
Step 3 — Medical Release Form (Mandatory)
Authorization to Release Medical Records
I authorize Refua and its assigned licensed clinicians to securely obtain, review, and use my medical
records from my previous healthcare provider(s) for the purpose of conducting a private virtual
medical checkup. I understand this authorization complies with the Personal Health Information
Protection Act (PHIPA) and that my data will be handled per Refua’s Privacy Policy. This release is
valid for one (1) year from today unless I revoke it in writing.
• Electronic Signature (type full name)
• Date of Authorization
By signing, you consent to secure retrieval and storage of your health records in Canada.
Step 4 — Upload identification
Upload one valid government photo ID: Driver’s Licence, Passport, or Ontario Photo Card.
Step 5 — Book your appointment (live API)
After submission, you’ll see live clinician availability via our secure scheduling API. Choose a date
and time for your encrypted video session with an Ontario-licensed GP or NP.
Step 6 — Additional details (optional)
Insurance Provider (optional) · Current Medications / Conditions · Notes or Special Requests
Submit & Proceed to Booking
You’ll receive a confirmation email with your signed authorization and appointment details. A
coordinator may contact you to confirm your video setup and ID before the session.
Need help? hello@refua.ca · 1-800-REFUA-CA (Mon–Fri)